=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568527067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVENANT HOSPICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 04/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3109 MINNESOTA AVE STE 150&160
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-5026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-785-3040
-----------------------------------------------------
Fax | 850-785-2552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5041 N 12TH AVE
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32504-8916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-433-2155
-----------------------------------------------------
Fax | 850-202-5819
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. ROLAND CLENEAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-433-2155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | 5025095
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------